A new analysis of 4,909 residents found that candidates who took the exam immediate after residency had an average first-time QE pass rate of 87%, compared with 57% for those who delayed 1 year and just 48% for those who delayed 2 years or more.

PATRICE WENDLING/Elsevier Global Medical News

“This idea of somehow thinking your results are going to improve if you wait a year is not borne out by the information we’ve shown,” study author and ABS associate executive director Dr. Mark Malangoni said in an interview.

While the study identified an association and not cause and effect, Dr. Malangoni and his colleagues suggest that poor performance is “most likely due to a deterioration of knowledge over time.”

That may not sit all that well with the average patient, who likes to think that physicians (like parents and even journalists) get smarter with experience.

Dr. Malangoni explained that one of two things may be going on. Roughly 80% of general surgery residents pursue a fellowship and focus on learning in a very narrow area. So, when they take the QE, which tests a very broad base of surgical knowledge, they may actually be forgetting things because of the narrow focus of their fellowships.

The second scenario is that the candidates start a practice, and the activities and stressors inherent in this new venture, may divert them from maintaining their knowledge base, he said.

Still others attending the recent Central Surgical Association meeting, where the study was presented, suggest that candidates who delay taking the QE may simply be poor learners or poor test takers.

Regression analysis, however, found that the effect was tempered but still significant after controlling for the candidate’s fund of knowledge using ABS In-Training Examination (ABSITE) scores. Undergraduate medical education and post-residency training also did not affect the results.

“There are a lot of reasons why someone might delay taking the examination and some of them are perfectly understandable,” Dr. Malangoni said. “I think the message we’d like to transmit to someone who’s thinking of delaying, is that if you’re able to adequately prepare for the examination, you should take it with that first opportunity right after completing residency because it appears, from what information we have, that that’s your greatest chance of being successful in passing the examination.”

Acute traumatic injury has been shown to produce a prothrombotic state that predisposes trauma patients to an increased risk of venous thromboembolic events. But are these patients also at increased risk for stroke?

Researchers at the University of Louisville report that trauma patients were 1.6 times more likely to develop a cerebrovascular accident (CVA) after admission than medical and surgical controls matched for known CVA risk factors such as age, hypertension, diabetes, atrial fibrillation, and tobacco use.

Dr. Smith called for more studies concerning the etiology and management of post-traumatic hypercoagulability and suggested that “CVA prophylaxis may be warranted in select trauma patients.”

The analysis identified 64 strokes after admission among 7,633 trauma admissions from 2008-2010, for an overall CVA rate of 0.8%. Out of this group, 23 strokes were found to be related to TBI and blunt cervical vascular injury, leaving 41 patients with non-injury related CVA in the analysis. The medical/surgical controls included 14,121 patients obtained from the university’s hospital database over the same time period.

When compared with a second control group of 120 trauma patients matched for Injury Severity Score and mechanism of action, the 41 trauma-related CVA patients presented with significantly more stroke risk factors, including older age, pre-existing hypertension, diabetes, and tobacco use.

Their chance of placement in an extended care facility also skyrocketed from 28% to 81%, while mortality rates more than tripled from 7% in controls to 22% in the trauma-related CVA patients, Dr. Smith and his co-authors reported.

The one bright spot was that on follow-up in the medical/surgical analysis, trauma patients had higher six-month post-CVA functional assessment compared with the controls.

Surgeons aged 35-50 years tend to have fewer complications during thyroid removal surgery compared with their younger and older peers, results from a multicenter French study show.

Courtesy Flickr/buzzthrill/Creative Commons

The findings “suggest that a surgeon cannot achieve or maintain top performance passively by accumulating experience, which raises concerns about ongoing training and motivation throughout a career that extends several decades,” according to the study, which was published Jan. 11 in BMJ. “Solutions to help surgeons avoid poor outcomes could include simulation and proctoring in the early years of their careers, continuous monitoring of performance, and targeted retraining if appropriate. Individual feedback based on outcome indicators might increase awareness about performance and improve safety in surgical practice.”

The researchers, led by Dr. Antoine Duclos, assistant professor of public health at the University of Lyon, France, evaluated data from 3,574 thyroidectomies performed by 28 surgeons at five French hospitals between April 1, 2008, and Dec. 31, 2009, (BMJ 2012 Jan. 11 [Epub doi:10.1136/bmj.d8041]). The main outcome measure was the presence of two permanent major complications 6 months following thyroid surgery: recurrent laryngeal nerve palsy or hypoparathyroidism.

The surgeons had a mean age of 41 years and had been in practice for a mean of 10 years. After adjusting for patient and surgeon variables, the researchers found that surgical experience of 20 years or more was the only factor significantly associated with an increased probability of recurrent laryngeal nerve palsy (odd ratio 3.06) and hypoparathyroidism (OR 7.56). They also observed what they described as a “concave association between surgeons’ experience and their case mix adjusted performance, suggesting that surgeons aged 35-50 years provided the safest care.”

The researchers acknowledged that other unknown or unexamined factors may explain part of the variation in patient complication rates, including the combination of manual and intellectual skills acquired during a surgeon’s academic and professional training. “Future studies should be conducted with larger populations of surgeons in various settings and other surgical specialties to corroborate the potential link between experience and performance,” they advised. “Since a cross sectional study might be inappropriate to resolve a dynamic phenomenon, a recommended design would be to follow a particular cohort of surgeons over time.”

Would you allow patients to self-refer for a CT lung cancer screening? Would you screen a never-smoker? What size nodule would trigger a follow-up exam? What is your lower age limit and lower pack-year limit for screening?

The NLST demonstrated a 20% reduction in lung cancer mortality when low-dose CT screening was used, compared to chest X-ray, among 53,000 asymptomatic current or former heavy smokers. However, CT produced more than three times the number of positive results and a higher false-positive rate than radiography.

Without a clear plan to manage abnormal findings or a firm handle on cost, policymakers and payors are hesitant to back reimbursement for widespread lung cancer screening. Results of the ongoing NLST cost-effectiveness analysis are expected early next year. Based on already published data, however, a crude back-of-the-envelope estimate puts the incremental cost-effectiveness ratio at $38,000 per life-year gained, NLST investigator Dr. William Black told attendees.

“That actually is a pretty good deal compared to a lot of things we do in medicine, and in fact most people would put the threshold for acceptability somewhere between $50,000 to $100,000 per life-year gained,” he said. “So it certainly is feasible”

Dr. Black pointed out that low-dose CT saved one lung cancer death per 346 persons screened in NLST, which again is very favorable compared to the rate of 1 per 2,000 patients for mammography.

Although the session provided just a small snapshot in time, audience responses suggest there is much work ahead. A full 77% of attendees were not using low-dose CT to screen for lung cancer and 72% reported not being familiar with the recently published National Comprehensive Cancer Network guidelines for lung cancer screening.

One-quarter of the audience had no lower age limit for screening, and 34% said they did not provide either decision support or obtain informed consent.

Radiologist and NLST collaborator Dr. Caroline Chiles said informed consent in NLST helped prepare patients for the potential risks of a screen, the likelihood of a positive result and that a positive result didn’t mean they had lung cancer.

“It made a huge difference once they got that letter saying they had a positive screen, because at that point you don’t want everyone rushing out to a surgeon to get that nodule resected,” she added.

What attendees and panelists could agree on is the need for smoking cessation to be included in any future lung cancer CT screening program, with 60% of attendees saying they already do so.

Dr. Chiles pointed out that 16.6% of participants in the NELSON lung screening trial quit smoking compared with 3%-7% in the general public, but that participants were less likely to stay non-smokers. She also cited a recent MMWR that found 70% of adult smokers want to quit smoking, but only about half had been advised by a health professional to quit.

“We really have to think of lung cancer screening as being a teachable moment,” she said.

She suggested physicians visit www.smokefree.gov for help in guiding their patients. Dr. Black also noted that the NLST team is working on a lung cancer screening fact sheet for physicians and patients that will be ready in a few weeks and made available on the Internet.

The quick answer to this question is yes, at least for many (as opposed to all) patients, and at least according to the bariatric surgeons I heard and spoke with at their society meeting in mid-June. My take from that meeting was that bariatric surgery is working wonders these days–of course for obesity, but for type 2 diabetes too. It’s remarkably safe, yet way underused. Will that change soon? Is a golden age of bariatric surgery dawning, and will the big, two-headed medical epidemic now rampaging get tamed as a result?

Roux-en-Y gastric bypass; courtesy NIDDK, Wikimedia Commons

It’s a tall order, but my bet is on bariatric surgery, and there are hints that its long-standing status as the wallflower of surgical interventions may be shifting.

Last March, the International Diabetes Federation issued a position statement on bariatric surgery saying that it should be “considered earlier in the treatment of eligible patients.” The statement called bariatric surgery “an accepted option in people who have type 2 diabetes and a body mass index of 35 kg/m2 or more.” And for patients with a BMI of 30-35 kg/m2 the statement said that bariatric surgery “should be considered an alternative treatment option” for patients inadequately controlled by optimal medical therapy, especially when they also have major cardiovascular disease risk factors.

To someone like me, previously unfamiliar with where bariatric surgery stood these days, some of the facts I gleaned at the meeting were eye-opening. The perioperative mortality rate for laparoscopic gastric bypass surgery (Roux-en-Y), the type of bariatric surgery considered most practical and effective for treating types 2 diabetes by most surgeons I ran into, fell to a rate of 6/10,000 patients treated in 2009 at about 360 U.S. academic medical centers and affiliated hospitals. The non-fatal complication rates and need for repeat hospitalization was also low, placing the risk from bariatric surgery these days squarely in the ranks of many “routine” surgeries, such as hip replacement, appendectomy, and gallbladder removal for stones. Gastric band placement is safer still, though not as effective for resolving type 2 diabetes.

The diabetes effect from gastric bypass is also impressive. One recent study compared 46 patients with diabetes who underwent laparoscopic gastric bypass at the Gundersen Lutheran Health System in La Crosse, Wis., with 41 matched patients with type 2 diabetes who remained on their standard medical treatment during 2001-2005. One year after surgery, the average hemoglobin A1c in the surgery patients stood at a normal 5.8%, compared with their average baseline value of 7.4%. Twenty-seven of these 46 (59%) were in full diabetes remission, meaning they were off all diabetes medications and their HbA1c was below 6.0%. In contrast, just 2 of the 41 conventional-treatment patients (5%) went into remission a year after their baseline.

“If there was a pill that achieved remission rates like this and had a safety profile like this and you didn’t offer it to your patients it would be unethical,” said Dr. Shanu N. Kothari, director of the minimally invasive bariatric surgery center at Gundersen and lead author of this study.

Yet bariatric surgery is neglected by most patients–be they just obese or obese with type 2 diabetes–and by their physicians. At the meeting I heard that about 200,000 U.S. bariatric surgeries are done annually now, a scope dwarfed by the number of patients who are candidates.

Why the neglect? Several surgeons at the meeting noted the disconnect between acceptance in the medical community of bariatric surgery relative to just about every other type of medically driven surgery out there.

What’s also striking is that bariatric surgery’s success contrasts with the problems that medical weight loss and maintenance has faced recently. During the past year or so, the Food and Drug Administration has shot down lorcaserin (Lorqess), the combination of phentermine and topiramate (Qnexa) , and another combination, bupropion and naltrexone (Contrave), all because of concerns that these agents might cause cardiovascular adverse events. In contrast, a report at the bariatric surgery meeting showed that all forms of bariatric surgery actually led to significant reductions in cardiovascular disease events as well as increased patient survival.

With medical management of obesity in sorry shape, and lots of evidence building for surgery’s safety and efficacy, the ascendance of a surgical solution to obesity and diabetes may have begun.

Enhanced Recovery After Surgery (ERAS) protocols have been hyped as “simple solutions” for accelerating recovery after colonic resection, although the quantity and quality of evidence supporting their ability to improve periopertive care and decrease postoperative complications is limited, Dr. Mary-Anne Aarts said in a presentation at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) in San Antonio last week.

Image via Flickr user praction^r by Creative Commons License.

One ERAS metric that shows consistent improvement across the available studies, however, is hospital length of stay, said Dr. Aarts who, along with her colleagues in the department of surgery at the University of Toronto, have identified (via a retrospective study of 366 consecutive colorectal resection patients at seven University of Toronto hospitals) the five “most important” ERAS strategies that contribute to the success in this domain.

These include:

Preoperative counseling regarding early discharge.

Omission of an oral bowel movement preparation.

Use of a laparoscopic approach.

Initiation of clear fluids on day of surgery.

Early discontinuation of the Foley catheter.

While the identification of these strategies does not address the quality of care and complication issues that have to be evaluated in large, prospective, collaborative studies before ERAS protocols will be widely accepted, it offers specific targets for investigation, which in turn could streamline research efforts, according to Dr. Aarts.

Dr. Jo Buyske challenged her SAGES colleagues to share their gifts with those in need. Photo by Diana Mahoney

Toward this end, the University of Pennsylvania adjunct professor and associate executive director of the American Board of Surgery spearheaded a series of initiatives that debuted at the conference. On Thursday, a group of meeting attendees boarded a bus to a Habitat for Humanity construction site where they swapped their surgical scrubs and scalpels for hard hats and hammers to help build a new home for a low-income family. The following day, SAGES sponsored an on-site donor blood bank and a bone marrow testing station at the convention center – both of which were well utilized between sessions – and a number of SAGES surgeons offered to mentor local high school students with an interest in medicine who had been invited to the meeting for the day.

Throughout the week, attendees dropped off used medical text books for medical schools in China and old medical instruments and supplies that for shipment (via Medwish) to the Albert Schweitzer Hospital in Haiti. During the course of the week, SAGES members also gathered information about international volunteerism from the several medical volunteers’ desks located near the SAGES membership booth and Dr. Buyske announced the formation of a SAGES humanitarian task force, charged with identifying new service opportunities and resources for its SAGES members.

The very vocal call to arms is more than just lip service for Dr. Buyske. In her presidential address, aptly titled, “To Whom Much is Given, Much is Required” [Luke 12:48], she described her own humbling experiences as a surgical volunteer in remote villages of Chiapas, Mexico; Bohol, Phillipines; and in the Republic of Mozambique, where access to sufficient water and electricity was erratic, at best, and where all of the niceties of surgery in this country, such as having assistants to help scrub, glove, and gown, as well as prepare and handle instruments, were non-existent. “I was not prepared for things as simple as having to pick up and unwrap my own instruments and choosing which sutures to use and which size needle. I was used to having everything handed right to me. It takes a different part of you brain to think about these things.”

Despite at various times having to pull anesthesia tubing from the trash to reuse it, having such poor lighting that she had to wait until the afternoon sun was just right in to perform cesarean sections, and having to use water from the local stream to scrub, Dr. Buyske said that each of the volunteer experiences made her a better person, and a better surgeon,. “You begin to think hard about what you use and why; you become more flexible; and you become more frugal. You revisit surgery in a way you might not have since medical school or residency. And though you’ll be exhausted, you will also be refreshed.”

As surgeons, “we have the great good fortune of doing work that allows us to go to bed every night knowing that just by doing our jobs, by our livelihoods, we have taken care of people; we have improved lives; we have done good. We should pause for a minute and savor the great good fortune, the luck, the wisdom, the hard work that went into a profession that is so fulfilling. but we should also be good stewards of our skills and our good fortune and take advantage of opportunities to be of service,” Dr. Buyske stressed. “As our Japanese friends and colleagues can tell us, our fortune and status can’t be taken for granted. There is no guarantee that it will be with us, even tomorrow.”

Thoracic surgeon Dr. Cameron Wright is a Colonel in the Medical Corps of the US Army Reserve. Image courtesy of MGH.

Dr. Buyske’s pledge to service was echoed by Dr. Cameron Wright, during the meeting’s Gerald Marks Lecture. A respected thoracic surgeon at Boston’s Massachusetts General Hospital, Dr. Wright is also a colonel in the Medical Corps of the US Army reserve, which he joined in 2007, “for many reasons,” including the obvious need for qualified surgeons to deal with the many casualties of the wars in Iraq and Afghanistan, and the opportunity to experience war surgery, he said. The most important reason, however, was the fact that his son, a heavy weapons specialist in the US Marine Corps “had skin in the game, and I decided I should put my skin in the game as well.”

In a moving slide presentation, Dr. Wright told his story through dramatic pictures, both of the soldiers with whom he served with and those to whom he ministered. Evident in all of the pictures are the camaraderie and sense of shared purpose that pervades military deployments, but also the human destruction that begs for the hands of a skilled surgeon.